Objectives Assess and diagnose pat

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                                            Objectives

Assess and diagnose patients with ADHD, GAD and MDD.
Develop plan of care for patients with complex mental disorders
Advocate health promotion and patient education strategies for patients with complex mental disorders.

Subjective:

CC (chief complaint): “It is hard for me to stay on task”

HPI: a 35 years old white female who presents at the clinic for her initial psychiatric evaluation. Patient has no psychiatric history and is not currently prescribed any psychotropic medications. Patient stated that she needs help with managing her symptoms. Patient stated that she did a lot of online research about her symptoms and believes she has ADHD. She reported struggling with staying on task, procrastinating a lot, being forgetful, having difficulty with keeping attention, being easily distracted, having difficulty concentrating, and misplacing
things. She is a business owner and said she worries too much over everything, has trouble relaxing, is restless, reports anhedonia, feeling down/depressed, hopeless, insomnia, tiredness, difficulty falling/staying asleep, and racing thoughts. This has been ongoing since her early childhood; her mom had been very supportive. Patient has never seen a psychiatrist or been diagnosed due to her mom’s belief. Her appetite is good. She denies suicidal/homicidal thoughts and no self-mutilation behaviors.

Past Psychiatric Hx: 

General statements: no past psych diagnosis
Caregivers: none
Hospitalizations: denies
Medication trials: denies
Psychotherapy/previous psychiatric diagnosis denies

Substance Current Use: use Marijuana 1-3X a month for 11 years

Family Psychiatric Hx: Uncle- GAD

Psychosocial Hx: Patient was born and raised in Houston, Texas. She has a bachelor’s degree in business management and is currently a business owner. Patient lives with her boyfriend, and they have been engaged for 3years. She enjoys traveling, painting, and listening to music. She denies any childhood trauma and legal problems.

Medical History: denies

Current Medications: denies
Allergies: pollens
Reproductive Hx:patient started menstruation at 14years, has no children and never been pregnant. Patient is heterosexual, sexually active and engage in vaginal sex. 

ROS: 

GENERAL: no weight loss, fever, chills, weakness.
HEENT: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: no chest pain, no palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: no nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: no incontinence, no burning on urination, urgency, hesitancy, odor, odd color.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: no muscle/ back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance.

Objective:

Diagnostic results: none available to review. Vital signs WNL. Will order CBC with differential, CMP, BMP, TSH, Free T4, Urinalysis, Urine drug test, Pregnancy test, and Vitamin D to screen for general medical problems, rule out medical causes of psychiatric symptoms, and to record baseline data before prescribing medications that may lead to abnormal labs.

Assessment tools: PHQ-9 (18), GAD-7 (17), Adult ADHD self-report scale (positive), MDQ (negative).

Assessment:

Mental Status Examination: Patient S.D is a 31 Y/O female who looks her stated age and appears casually groomed. She is cooperative with examiner, forthcoming, with good eye contact. There is no evidence of abnormal motor activity, psychomotor agitation, or retardation. Her speech is clear, normal in rate, rhythm, and volume. Her thought process is logical and organized. Patient appears anxious, sad, and hopeless; her mood is congruent with affect. There are no apparent signs of auditory, visual hallucinations. There is no evidence of delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, she is alert and oriented X4. Her cognitive functioning, short and long-term memories are intact. Her concentration is fair, attention is distracted, short-span, hyper and restless. Her insight and judgement are good.

Differential Diagnosis:

Attention Deficit Hyperactivity Disorder (ADHD), predominantly inattentive type: ADHD is a neurodevelopmental disorder, usually first diagnosed in childhood, characterized by inattention, impulsivity, and/or hyperactivity (PsychDB, 2022). It is associated with deficits in executive function, including inhibitory control, working memory, and effortful attention. Adolescents and adults with ADHD have a higher risk of earlier substance use, and greater difficulty with substance use (Steinberg et al., 2018). The DSM-V diagnostic criteria for ADHD include a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by at least 6 symptoms of inattention and or 6 or more symptoms of hyperactivity/impulsivity (APA, 2013). The symptoms must start prior to age 12, symptoms must be present in at least two settings (work, school, home, friends), and not better explained by another mental health disorder (APA, 2013). The patient meets the DSM-V diagnostic criteria for ADHD as evidenced by difficulty completing task, procrastinating a lot, being forgetful, having difficulty with keeping attention, being easily distracted, having difficulty concentrating, and misplacing things which affects her job and relationship with friends, and positive screening result on the Adult ADHD self-report scale.
Major Depressive Disorder (MDD), recurrent moderate without psychotic features: MDD is a mental disorder characterized by persistent, often daily, low mood and/or decreased interest (anhedonia). There are also associated neurovegetative symptoms, such as a change in sleep, appetite, cognition, and energy levels (APA, 2013). The patient meets the DSM-V diagnostic criteria for MDD as evidenced by anhedonia, feeling down/hopeless, insomnia, little energy, trouble concentrating on things (APA, 2013); and PHQ-9 screening score of 18. Patient also reports onset of symptoms since childhood.
Generalized Anxiety Disorder (GAD): GAD is mental disorder characterized by excessive anxiety and worry about multiple events or activities (e.g. – school or work difficulties, relationships, finances) on most days over at least half a year. There are also associated symptoms, such as restlessness, muscle tension, fatigue, poor concentration, irritability, and sleep changes (APA). The patient meets the DSM-V diagnostic criteria for GAD as evidenced by feeling anxious/worried about everything, not being able to control worry, irritability, trouble relaxing and feeling afraid since childhood (APA, 2013); and GAD-7 screening score of 17.

Reflections: Based on the case scenario, I have learned the symptoms and similarities between GAD, ADHD, and MDD and how they can co-occur in patients. This patient is hard to diagnose because of the interlapping symptoms that fit the three diagnoses listed above. In addition to the DSM-V diagnostic criteria, a comprehensive psychiatric interview with a detailed review of medical history and childhood developmental history is required to diagnose ADHD accurately. ADHD is sometimes over diagnosed; therefore, clinicians must ensure detailed psychiatric and developmental history assessment (Kazda et al., 2021). An ethical/legal factor that should be considered includes obtaining informed consent, teaching on side effects of medications of choice, health promotion education on substance use, sleep hygiene, and lifestyle modifications for ADHD management.

Case Formulation and Treatment Plan

Medications:
Start Escitalopram 10mg by mouth qd for MDD/Anxiety management, #30
Start Strattera 40mg by mouth qam for ADHD management, #30

Non-stimulants are second-line treatment agents and can be prescribed for patients with high risk of stimulant abuse. Patients with ADHD who use substances are at high risk for stimulant abuse (Martinez-Raga et al., 2017). Therefore, a non-stimulant is recommended for this patient due to its less abuse potential. SSRIs are first-line treatment agents for depression.

Future plan: Monitor for improved concentration/focus, mood, decreased anxiety, improved sleep.

Psychotherapy: Refer patient for CBT for ADHD, MDD and Anxiety management. Time management and organizational skills are addressed in CBT targeted for ADHD (Lopez et al., 2018).
Psychoeducation: Explained the rationale for the diagnosis, Discussed available treatment options (both pharmacological and non-pharmacological). Risk and benefits of medications discussed including potential side effects of straterra (decreased appetite, insomnia, GI distress, decreased libido, anxiety, dry mouth, increased heart rate, increased blood pressure), and Escitalopram. Advised not to stop medications abruptly without speaking with the provider. Advised patient to stop substance use. Educated patient on behavioral and psychosocial interventions in the environment for ADHD management:
Implement structure and routines
Use organizational apps such as Evernote, Omnifocus. 
Post visual reminders such as sticky notes and calendars in prominent locations
Use timers/apps for deadlines.
Provided supportive listening. Time allowed for questions and answers provided.
Patient referred for complete blood work
Follow up for medication management in 2wks

Patient is amenable to this plan and agrees to follow treatment regimen as discussed.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., (DSM-5). Washington, DC: American Psychiatric Publishing; 2013. 

Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA Netw Open. 2021;4(4): e215335. doi:10.1001/jamanetworkopen.2021.5335

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2018). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2

Martinez-Raga, J., Ferreros, A., Knecht, C., de Alvaro, R., & Carabal, E. (2017). Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes. Therapeutic advances in drug safety, 8(3), 87-99. https://doi.org/10.1177/2042098616679636

PsychDB. 2022. Attention-Deficit/Hyperactivity Disorder (ADHD). [online] Available at:  

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